Patient Contributions Research Articles

The Dignity of Creating: The Patient's Contribution to the “Reachable Enough” Analyst

Through the defining power of words, the phrase “difficult-to-reach” patient reflects the extent to which the analyst inverts the patient's will to change and makes the analyst the subjective agent of treatment progress. If making a constructive contribution to another person's life engenders a sense of creative agency, the traditional dichotomies of analyst/helper who gives and an empty patient who receives may not be useful. I trace the evolution of a 23-year-long psychotherapy from a parent–child dynamic through to more uncertain relational terrain in order to illustrate how the analyst's own evolution may have clashed with the patient's ambivalence toward change and endings. I raise questions of how the dignity of making a creative contribution to the “reachable enough” analyst's life may enable the patient to work through gratitude, attain a sense of belonging, and terminate with good conscience.

The PRIME project: developing a patient evidence-base.

The concept of evidence has become firmly rooted in health care, with most importance placed on the outcome of research in clinical and economic spheres. Much less emphasis is placed on the patient's contribution to evidence which remains relatively vague, of low status and often difficult to integrate with other forms of knowledge. This article proposes a concept of patient-based evidence, to complement clinical and economic forms of evidence, and demonstrates one way in which it has been operationalized. The PRIME project developed a patient evidence-base to capture the lived experience of individuals with myalgic encephalitis (ME) or chronic fatigue syndrome (CFS). Interviews were performed with 40 individuals with ME/CFS who varied in a range of demographic characteristics, including age, gender, and how severely affected individuals were. PRIME has developed a patient evidence-base which has an extensive array of experiences data to provide researchers, clinicians and others with an in-depth insight into the lived experience of ME/CFS that can be used and analysed. Data are grouped into a wide range of themes, which can be downloaded and used in a variety of ways as a source of evidence to enable understanding of the lived experience of ME/CFS and so contribute to the development of a more patient-focused research agenda in ME/CFS. While patient-based evidence used in the PRIME Project provides a useful start, further work is required to develop this area conceptually and methodologically, particularly in relation to how patient-based evidence can be considered alongside clinical and economic evidence.

Doctor–Patient Communication in Glaucoma Care: Analysis of Videotaped Encounters in Community-Based Office Practice

To assess doctor-patient communication in patients with glaucoma. Observational cohort study. Twenty-three ophthalmologists and 50 patients with glaucoma. Doctor-patient encounters were audio- and videotaped and analyzed using validated sociolinguistic approaches. After the visit, the doctor and the patient completed questionnaires, and patients were interviewed using a semistructured, patient-centered protocol. Summary statistics about doctor-patient encounters, assessment of alignment of attitudes between patients and doctors, and patient admission to missing doses. Physicians spent an average of 8.0 (standard deviation [SD], 3.1; median, 7.8) minutes in the room with the patient and an average of 5.8 (SD, 2.4; median, 7.5) minutes talking with the patient, delivering 70% of all spoken words and asking two thirds of all questions. Glaucoma-related discussion occupied 50% of talk time and was focused primarily on examinations and treatment (25%). One third of discussions addressed ocular issues other than glaucoma. Virtually all physician questions (94%) were closed ended. Most patient questions were about intraocular pressure (20% of visits), details of the medication regimen (20%), disease status (14%), and testing (12%). Although physicians and patients were aligned in believing that the physician should control the visit agenda, physicians tended to support greater physician control of decision making than did patients. Physicians failed to identify most patients who admitted to missing doses, a surrogate for nonadherence, stating that 10 of 13 in this category were taking drops "all" or "most" of the time. Physician interviews detected 3 of the 11 patients whose postvisit questionnaire indicated missing a dose in the last week compared with 11 of the 11 detected by the postvisit research interview. Patients who stated they had missed doses recently reported being less satisfied with the doctor-patient encounter than those who did not. Doctor-patient dialogue was universally physician centered; physicians spoke 70% of the words and asked closed-ended questions that restricted the patient's contribution to "yes/no" or brief responses. A minority of physicians ever asked patients if they had questions. In contrast with the patient-centered research interview, doctors' physician-centered communication failed to identify most patients who had missed doses.

Passing the audition – the appraisal of client credibility and assessment by nurses at triage

This paper presents the findings of one aspect of a larger study aiming to build a substantive grounded theory of the process of initial assessment at triage. Prioritisation at triage within emergency departments centres primarily on assessing the threat to physiological function of people presenting with health-care problems. This approach presumes that clinical reasoning strategies reside exclusively within the health-care practitioner, with the patient playing no active part in the process. A grounded theory/symbolic interactionist methodology. Thirty-eight recordings were made of live triage encounters involving 14 emergency nurses from two demographically distinct emergency departments. At the end of the relevant shift, those encounters in which the nurses were involved were replayed to them. The recording was stopped after each question or comment by the nurse who was then asked to say what they were thinking at the time. The nurses' thoughts were recorded, transcribed and analysed using the constant comparative method, in which hypotheses are generated and continually modified in the light of incoming data until a conceptual story line, or theory, is produced. The findings suggest that the outward clinical signs of problems presenting to the emergency department were not viewed by nurses as neutral manifestations of the pathology itself but as a conscious or unconscious portrayal of patients' physical discomfort and their perception of the nature of the problem. The way in which patients and carers depict their problems is used by triage nurses to determine the credibility of the clinical information they provide. Triage can be regarded as a process in which nurses act as an adjudicating panel, judging the clinical data before them through the appraisal of the way patients act out their problems and narrate their stories. Nursing practice and research need to account for the patient's contribution to the decision-making process at triage.

Crash: What We Do When We Cannot Touch: Commentary on Paper by Meira Likierman

This commentary aims to show the congruence and difference between Likierman's position on recognizing otherness and working with enactment and her relational, intersubjective position. Differences in my reading of the case include stressing the repetition of early attachment trauma, the level of implicit procedural relating, and the patient's contribution to the shared third of rupture and repair. I try to show that enactments arise not merely because the patient is able to pull the patient into forbidden behavior but because the dissociated parts of the patient pull the analyst into dissociation even when the analyst is acting “properly.” The rupture or collision—the “crash”—that the patient helps to formulate represents an opportunity to see the life-giving element in what we, analysts along with patients, inevitably also experience as frightening and even life-threatening.

The myths of free association and the potentials of the analytic relationship

The author challenges the traditional and still prevalent view of ‘free association’, arguing that it entails three forms of denial (also formulated in terms of corresponding myths): 1) denial of the patient's free agency; 2) denial of the patient's and the analyst's interpersonal infl uence; and 3) denial of the patient's share of responsibility for co‐constructing the analytic relationship. That responsibility includes some degree of consideration of the analyst's needs. Sometimes, the patient's good judgment to that end may be refl ected in what is automatically and mistakenly reduced to a form of ‘resistance’. Attention to the patient's responsibility must be balanced against the effort to provide a uniquely safe environment for the patient's revealing of shame and anxiety‐ridden feelings and attitudes. But the therapeutic action of psychoanalysis, ideally, includes the cultivation, through lived experience, of the dialectical interplay of self‐expression, on the one hand, and caring relational engagement, on the other. Recognition of the patient's free agency does not preclude exploration of constraining structures laid down in the past. On the contrary, it deepens such exploration. At the same time, it opens the door to the possibility of explicit recognition, via challenge, criticism, or affi rmation, of the patient's contributions to the analytic work.

Patient contribution to the medical dialogue and perceived patient-centeredness

Relatively few studies have directly addressed the interaction dynamics and consequences of a companion's presence in the medical visit, and their findings have been contradictory. To examine how patient's contribution to the medical dialogue, with or without the presence of a visit companion, is related to the perception of the medical visit as patient-centered. Observational study using pre- and postvisit questionnaires and audiotape recording of medical visits. One hundred and fifty-five patients aged 65 or over; 63 in medical visits that included the presence of a companion and 82 in visits that did not include a companion. Patient ratings of visit patient-centeredness. Long visits (greater than 10 minutes long) and visits in which patients were verbally active were rated as more patient-centered by patients than other visits. Since patients were generally less verbally active in visits that included a companion, accompanied visits, especially if they were less than 10 minutes long, received lower patient-centered ratings than others. The presence of a companion was not related to length of the visit, suggesting that the verbal activity of the companion was off-set by decreased verbal activity of the patient. Our results have suggested that patients are more likely to perceive their physician and visit as patient-centered when they have an opportunity to engage directly in the medical dialogue. A minimal amount of "talk-time" for patients themselves should be safeguarded even in a short visit, when a companion is present.

Don?t You Know Me? Mutual Recognition in a Case of Mistaken Identity

Contemporary relational theories in psychoanalysis recognize the fully two-person nature of the clinical process. Both patient and therapist bring to the encounter their internal worlds in equal measure, each exerting constant influence on the other, to create a highly complex relational field. From this perspective, clinical vignettes should provide the same level of description of the therapist's as of the patient's contributions to the treatment process. It is argued that the body of clinical relational literature, in general, has not kept up with its rich theoretical contributions. This case vignette and discussion, both in structure and content, is an in-depth illustration of the mutual construction of the clinical process. Clinical material is offered from an extended phase of analytic treatment during which the therapeutic relationship and so the patient's possibilities for growth and change shifted from seeming stasis and impasse into new realms of experience of self and others. The author's intent is to demonstrate with specificity the ways in which the experiential worlds of patient and therapist collide and influence each other to create the intersubjective field that is the locus of therapeutic action and analysis. The phase of work described in this paper was challenging and ultimately successful due both to the severe and pervasive nature of the patient's struggles along with his underlying courage to persevere in the face of them, and to the ways in which the therapist's life experiences and capacities inescapably contributed to the shape, limitations and possibilities of the therapeutic process.

Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting.

This study examined differences in the assessment of symptoms and quality of life (QoL) between patients with advanced cancer living at home and their specialist palliative care nurses. Nurses introduced a recently validated outcome measure, the Palliative Care Outcome Scale (POS), to patients referred to their hospice at their first or second home visit. The POS has two components: a patient questionnaire mirrored almost exactly by a staff questionnaire, which are both completed independently. The POS contains 10 core questions examining aspects of symptom control and QoL. Of the 338 patients referred during the study period, 174 (51%) were eligible for inclusion in the study. Of these, 55 (32%) pairs of patient and nurse questionnaires were returned and suitable for assessment. Not all questionnaires were returned by nurse and patient to form a matched pair. There was good agreement and correlation between patients and nurses in the assessment of pain and symptom control. However, important differences were found in other areas explored including anxiety levels of patients and their families, personal thoughts, practical matters and information received. The study confirms the importance of evaluating the needs, feelings and concerns of patients with advanced cancer cared for at home and highlights both the significance and necessity of the patient's contribution to any such assessment.

Discussion of Gay Patient-Gay Therapist

Abstract This discussion of a case report focuses on the ubiquity of polarized thinking in formulating therapeutic concepts. Binary thinking afflicts the two sides of the essentialist-social constructivist debate. Both views avoid the fact that we can never really know where biology stops and culture begins. The classical view of transference is another type of binary thinking that diminishes the ambiguity that arises if one considers both the analyst and patient's contributions. It is argued, instead, that transference is not something projected onto a blank screen, but rather something that occurs between a therapist and patient based on subjective factors unique to each of them.

Symptom Study in Context: Effects of Marital Quality on Signs of Parkinson’s Disease during Patient-Spouse Interaction

Hypokinesia, the inability to initiate or maintain movement, represents one of the most disabling aspects of Parkinson's disease (PD), and displays intriguing moment-to-moment variability from environmental stressors. Correlates of orofacial hypokinesia (characteristics of spontaneous eye blink and speech) were coded from videotaped interactions for PD patients in maritally distressed and nondistressed dyads. Significant changes occurred only for the patients in distressed relationships on the two strongest neurophysiologic measures of orofacial hypokinesia, rate and duration of spontaneous eye blink. Further analyses suggest two possible explanations for these temporal symptom changes. Distressed spouses may exacerbate symptoms by exposing the patient to negativity. Alternately, nondistressed spouses may compensate for the demands of the interactional task by assuming a greater share of the conversation relative to the patient's contribution. Results are linked to existing literature; the role of social and familial support in chronic illness is discussed.

The patient's contribution to the therapist's countertransference feelings.

Countertransference feelings of psychiatric milieu therapists toward their patients were studied by using a self-report feeling word checklist. The feelings were scored on subscales of feeling states in a circumplex model. By using an analysis of variance model, comparisons between reactions to patients individually and reactions to patients with different personality organizations and with different Health-sickness rating scale scores could be made. A total number of 244 therapists at 21 small treatment homes were studied. It was found that approximately 15% of the therapists' countertransference feeling reactions could be accounted for by recurrent reactions to patients individually. Surprisingly, the personality organization and the Health-sickness rating scale score of the patient accounted for almost no variance in therapists' feelings. The results are discussed, and possible explanations are evaluated.

Encouraging patient participation in general practice consultations: Effect on consultation length and content, patient satisfaction and health

Abstract Following the evidence from earlier research that one-to-one interventions can increase the patient's contribution to the consultation, this paper reports the results from a randomised control trial which assessed the effects of a leaflet designed to enhance patient participation in consultations. A random sample of patients (aged 16 to 74) waiting to see a general practitioner were given either an intervention leaflet, which encouraged the patient to take an active role in the consultation, or a control leaflet which gave dietary advice. The effects of the intervention were assessed by measuring length of consultation, number of questions asked by the patient, patient satisfaction score, doctor's feelings about the consultation, the change in patients' health in the 4 weeks following the consultation (measured by the SF-36 Health Survey) and the number of patient visits to a GP in the following year. The results showed that patients in the intervention group had significantly longer consultation...

Ethics and Organ Use-Reply

<h3>In reply</h3> Weinrauch makes some important observations about the allocation of scarce resources. Using limited resources where they will provide the most benefit is a fundamental social goal. However, his concerns about the Council report reflect either misunderstandings about the report or a failure by him to give due weight to important social values other than maximizing overall benefit. First, Weinrauch takes some of the Council's guidelines out of the context of the full report and draws inappropriate conclusions as a result. As he observes, the Council rejects, as a criterion for allocation, the patient's contribution to disease. The Council noted that the patient's contribution to disease is often not voluntary, that it is difficult to determine how much the patient's need for treatment really can be traced to the patient's past behaviors, and that only certain deleterious behaviors are singled out for consideration.^1(pp32,33)However, it does not follow,

Ethics and Organ Use

The recent special article in theArchiveson the ethical considerations in the allocation of scarce resources by the American Medical Association's Council on Ethical and Judicial Affairs 1 begins a very important dialogue designed to provide a moral framework for patient care in any health care system. We hope to develop new criteria for the distribution of scarce resources (such as transplantable organs, high-tech, high expense, or experimental care) in the future, but we must recognize that no resource is unlimited. Thus, we will most assuredly find it necessary to allocate any resources on the basis of maximum benefit. The Council suggests that certain criteria for resource allocation are ethically unacceptable a priori. The statement that a patient's contribution to his or her own medical condition or repeated abuse of resources should not be ethically considered in the allocation of scarce resources relies on some rather specious arguments for

A selective review of the literature on nurse-patient communication: has the patient's contribution been neglected?

The literature on nurse-patient communication is selectively reviewed. Previous research has been critical of the quality and quantity of nurse-patient communication, describing it as brief and superficial. Nurses are depicted as controlling and restricting the course and topics of conversations with patients. Communication skills training for nurses has been advocated as a solution for this apparent deficit. In this paper it is argued that research has over-emphasized nurses' roles in nurse-patient communication, particularly their communication skills. The patients' contribution to the content and organization skills. The patients' contribution to the content and organization of nurse-patient communication has been largely ignored. Assumptions have been made about nurses' and patients' intentions and motives during nurse-patient conversations, but the participants, particularly patients, are rarely asked for their views. There has been a tendency to view nurse-patient communication in terms of isolated excerpts of conversation. When environmental and organizational factors are included, it is their effect on nurses' communication capability, not the patients', that are the interest. It is suggested that future research consider both patients' and nurses' contributions to nurse-patient communication.

Medical notes--the patient's contribution?

Over the past five years I have been an outpatient at three hospitals, have seen five consultants, and had countless appointments, all of which relate to the same illness. Each time I see a different doctor I have to relate the history of the illness, investigations, and treatment. The first time that I saw a different consultant I was unprepared. I found …

Indigent Patient Care--Then and Now

Care of the indigent patient was the physician's responsibility and privilege in the 1940s, as it had been for an eternity before. Every physician recognized his responsibility to provide this care and donated one half day or one whole day a week to the care of these patients. The care that the patients received was generally excellent and, in some instances, better than that provided for the paying patient. Often an effort was made to contain the expense of the patient with medium income so that he did not receive the generous laboratory testing and diagnostic workup, which was freely accorded to both the indigent and the wealthy. The patient's contribution was to provide an opportunity for medical students and residents to learn the rudiments of medicine and patient care from their illnesses. In cities, there were large hospital clinics, for the purpose of caring for indigents, staffed by the

Patient-oriented interventions to improve communication in a medical office visit.

Examined a simple intervention to improve the patient's contribution to communication in a medical office visit. In the first study, women awaiting a medical appointment were randomly assigned either to a group that was asked to list three questions to ask their physician or to a control group. Women who listed questions asked more questions in the visit and reported being less anxious. In the second study, a third group that received a message from their physician encouraging question asking was added. Both experimental groups asked more of the questions they had wished to, had greater feelings of control, and were more satisfied with the visit in general and with the information they received. The two experimental groups did not differ significantly, suggesting that the effect may be attributed either to thinking one's questions out ahead of time or to the perception that one's physician is open to questions.

Medical and surgical inpatients who referred themselves for psychiatric consultation

Medical and surgical inpatients who referred themselves for psychiatric consultation are characterized. The 25 “self-referred” compared to 787 “others” referred to the Consultation-Liaison Psychiatry Division were more likely to state depression ( 52% 25% ) and anxiety ( 36% 11% ) as reasons for referral. “Self-referrals” were less likely to be referred by physicians for behavior management ( 8% 23% ), general diagnosis ( 4% 22% ) or suicide evaluation ( 4% 25% ). The “self-referral” represents a challenge to the current medical model referral mechanism in which the physician controls access to consultants. The data indicate that there should be a mechanism for the patient's contribution to the referral process and that increased sensitivity to psychologic difficulties in coping with medical illness would improve the use of psychiatric consultation in the medical setting.